| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
258 |
160 |
$40K |
| D1120 |
Prophylaxis - child |
757 |
757 |
$25K |
| D9310 |
|
333 |
333 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
598 |
598 |
$22K |
| D0330 |
Panoramic radiographic image |
278 |
278 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
937 |
691 |
$11K |
| D0272 |
Bitewings - two radiographic images |
365 |
365 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
705 |
705 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
438 |
433 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
40 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
67 |
62 |
$3K |
| D1110 |
Prophylaxis - adult |
44 |
44 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$2K |